Dr Ben Mullings

A literature review of the

evidence for the effectiveness

of experiential psychotherapies

© PACFA, March 2017

This publication is copyright. No part may be reproduced by any process except in

accordance with the provisions of the Copyright Act 1968.

Suggested citation :

Mullings, B. (2017). A literature review of the evidence for the effectiveness of experiential

psychotherapies. Melbourne: PACFA.

Correspondence concerning this article should be addressed to:

Dr Ben Mullings

Email: contact@drben.com.au

Contents Foreword ................................................................................................................................................. 1

Abstract ................................................................................................................................................... 2

Introduction ............................................................................................................................................ 3

Method ............................................................................................................................................... 3

Results ................................................................................................................................................. 4

General Findings ................................................................................................................................. 6

Discussion.......................................................................................................................................... 15

Conclusions ....................................................................................................................................... 17

References ............................................................................................................................................ 18

Appendix 1 .................................................................................................................................... 22

Appendix 2 .................................................................................................................................... 23

Appendix 3 .................................................................................................................................... 27

Page | 1

Foreword

This publication of a literature review of research into the effectiveness of experiential

psychotherapy, conducted by Dr Ben Mullings, is intended as a resource for counsellors,

psychotherapists, students and academics in our profession. The review demonstrates beyond

doubt the effectiveness of experiential psychotherapies for a range of psychological conditions,

and its equivalence to other modalities. Dr Mullings' intelligent discussion of factors affecting

research findings, including researcher allegiance and use of unspecified control conditions, has

broader relevance to our field.

The PACFA Research Committee recognises the importance of counsellors and psychotherapists having access to recent research evidence that demonstrates the effectiveness of their practice. The Australian public deserves better quality information about the range of effective modalities available to them, to promote greater choice in mental health interventions and strategies to promote wellbeing.

This review is one of a series of reviews commissioned by the PACFA Research Committee to support PACFA members and member associations in their work. The Committee recognises that there is strong research evidence for the effectiveness of all modalities of counselling and psychotherapy. The Common Factors research, in particular, has shown the centrality of the therapeutic relationship, and the relatively minimal relevance of specific techniques, to positive therapeutic outcomes.

The Research Committee is committed to supporting the profession to develop the research base demonstrating the effectiveness of counselling and psychotherapy modalities.

We hope that you find this review, and others in this series, useful in your own research, practice and advocacy. We welcome your feedback.

Dr Ione Lewis PACFA Research Committee Chair March 2017

Page | 2

Abstract

The purpose of this literature review is to review the evidence base for the effectiveness of

experiential psychotherapies, conducted in international and Australian settings. A systematic

review of internationally published research from the last five years, and Australian research

from the last 10 years, was conducted using PsychINFO, Google Scholar, and Web of Science

databases. The findings of research studies included in this review have been integrated with the

findings of previous meta-reviews on experiential psychotherapies. Five meta-reviews and 14

recent studies met the inclusion criteria. There is a very high standard of evidence for the

effectiveness of experiential psychotherapies with depression, medical conditions and

unresolved relationship concerns. Experiential therapies are equally efficacious in improving

psychological coping compared to other interventions, including Cognitive Behavioural Therapy.

The evidence for the effectiveness of experiential psychotherapies with anxiety is weaker, and

further research is needed. Experiential therapists need to be willing to participate in research to

build the evidence base for this modality.

Keywords: Experiential psychotherapies, humanistic tradition, emotion-focused, gestalt,

psychodrama, expressive, focusing-oriented, effectiveness, evidence-base

Page | 3

Introduction

Experiential psychotherapies originate from the humanistic tradition. This class of approaches

include emotion-focused, existential, person-centred, gestalt, psychodrama, focusing-oriented,

and expressive therapies. Experiential approaches share a set of core qualities, such as eliciting

and exploring reflective experiences in-session, using empathy within the therapeutic

relationship as a curative factor, and helping people to explore and make meaning of their own

inner lives.

It has frequently been the case that researchers from other therapy traditions have described

relationship control groups as ‘supportive’ or ‘non-directive’. An unfortunate consequence has

been confusion with inactive controls which are not intended to be genuine therapy approaches.

A growing number of contemporary approaches from outside of the humanistic tradition have

also now begun to integrate elements of experiential therapy (Angus, Watson, Elliott, Schneider,

& Timulak, 2015).

Historically speaking, the experiential tradition has opposed psychiatric classification on the basis

that diagnostic categories are conceptually flawed, needlessly based on dehumanising criteria

(such as biomedical centrism), and have at times been used to restrict freedom and choice for

people who seek psychological care (Cain, Keenan, & Rubin, 2016). Therapists have increasingly

relied upon research evidence to support their practices (i.e., evidence-based practice) and to

demonstrate that therapeutic interventions are effective, in the context of growing pressures

from third party providers who fund mental health care. Therefore, it is now vital to be able to

demonstrate that experiential therapy is effective for specific problem areas.

Method

This review draws together findings from meta-analytic reviews, well-controlled randomised

clinical trials (RCTs), and key texts or journal articles relevant to the current practice of

experiential psychotherapy in Australia.

Search Strategy

Target keywords were entered in the PsycInfo database to generate a primary search list, which

was expanded through use of Google Scholar and Web of Science. The list of keywords

corresponded with names of each main therapy sub-type from the experiential psychotherapy

tradition (e.g., ‘existential psychotherapy’ OR ‘emotion focused therapy’ OR ‘gestalt approach’).

The full list of keywords and variations are shown in Appendix 1. Search results were limited to

studies and articles published in peer-reviewed journals, written in English, and directly relevant

to therapy. This search focused on publications from the last five years internationally, and the

last 10 years in Australia. Recently published research was then integrated with findings of prior

meta-analytic reviews to build on the current state of knowledge relevant to experiential

psychotherapy.

Page | 4

Inclusion and Exclusion Criteria

All identified studies with well-established measures of symptom severity or behaviour change

were included. In addition, this review includes qualitative research directly relevant to therapy

outcomes. Purely theoretical articles, and process research without a clear link to therapy

outcomes, were excluded. Likewise, treatment comparisons without rigorous methodology were

excluded.

Due to the deeply relational nature of experiential psychotherapy, studies relevant to couple

therapy, group therapy, and family therapy were included alongside individual psychotherapy.

For ease of comparison of findings between studies, studies were rejected if the type of

intervention was self-help, online, or provided by telephone.

Results

A total of 14,767 search results were identified using the keywords shown in Appendix 1. This

pool of initial results was narrowed down to 303 articles by limiting to peer reviewed texts,

specifically about therapy and published within the last 10 years. Applying the inclusion and

exclusion criteria shown above, a total of 14 new studies was identified for inclusion. The

flowchart in Figure 1 provides a more detailed summary of articles included and excluded from

the current review.

Meta-analyses

Five meta-analyses were identified for inclusion in the review.

Elliott, Greenberg, Watson, Timulak and Freire (2013) provide a substantial update on prior

reviews which have appeared in Bergin and Garflield’s Handbook of Psychotherapy and Behavior

Change. This meta-analytic review adds 77 additional studies since the last revision of the

chapter in 2004, bringing the total number of included studies to 186. Data from the meta-

analysis shows a revival of outcome studies focused on experiential psychotherapy over the last

two decades.

Adding further specificity to the wider meta-analysis mentioned above, Elliott (2013) completed

a more targeted review focused on anxiety disorders. This review provides more in-depth

analysis and discussion relevant to the question of how recent outcome studies can inform

current therapeutic practice in Australia. Elliott’s discussion adds some valuable reflections

about the theoretical underpinnings of person-centred therapy, focusing-oriented therapy, and

emotion-focused therapy, in populations living with anxiety.

Hölldampf, Behr, and Crawford (2010) review the treatment outcomes for humanistic

counselling and play therapy for young people in a chapter of the text Person-centred and

Experiential Therapies Work. The review builds on eight major meta-analyses, including data

from 94 research projects, with outcomes linked both to specific mental health issues and

context-specific problem areas experienced by children and adolescents.

Page | 5

A meta-analysis of outcome studies in existential psychotherapy conducted by Vos, Craig, and

Cooper (2014) was also included. The review had limited inclusion criteria, requiring each study

to explicitly identify the intervention as being existential in focus. Within those limitations, the

reviewers identified 21 RCTs drawn from 15 samples comprised of 1,793 participants. Most

studies described meaning-based therapies (e.g., logotherapy) or supportive-expressive

therapies provided to medical patients with cancer and other medical illnesses.

This review also includes a qualitative meta-analysis by Timulak and Creaner (2010) to add

further descriptive detail about therapy outcomes. This review consists of nine studies exploring

the question, “what outcomes/effects are reported in qualitative studies investigating outcomes

of humanistic therapies?” (p. 72). The findings of qualitative and process studies have been

brought together with the outcome data shown above to summarise the state of current

evidence.

Figure 1: Search process for the inclusion of recently published research

Summary information about the 13 additional studies is provided in Appendix 2.

Initial search results via PsycInfo, Google Scholar, and Web of Science

(N = 14,767)

Articles with peer review, about therapy, published in last 10 years

(N = 303)

Excluded

• Interpretative phenomenological analysis (IPA) without reference to experiential therapy (N = 157)

• Used a “constructivist approach” without reference to experiential therapy (N = 14)

• Studies about management, education, coaching, or law enforcement, referring to “experiential learning” (N = 7)

• Studies not in English (N = 12)

• Already included in most recent review by Elliott et al., 2013 (N = 7)

• Otherwise not relevant: theoretical papers, commentary, book reviews, not bona-fide therapy in study, and other unrelated research (N = 92)

• Poor methodological rigour (N = 1)

Excluded

Did not meet initial criteria (N = 14,464)

Added to the review (N = 13 additional studies)

• Randomised (N = 8)

• Pre-post Outcomes (N = 9)

• With follow-up (N=4)

• Process research (N=4)

• Therapy comparison (N = 5)

• With waitlist control (N = 3)

Page | 6

General Findings

The meta-analysis by Elliott et al. (2013) is the largest and most comprehensive review of

humanistic-experiential psychotherapies (HEP) to date. The review included a total of 14,206

individuals, with 62 studies compared to wait-list/control (31 of which were RCTs), and 135

studies directly comparing HEP to other therapies (82 of which were RCTs). The average length

of treatment was 20 sessions.

Elliott et al. (2013) combined random effects model significance testing (Wilson & Lipsey, 2001)

with equivalence analysis, allowing them to demonstrate the relative levels of equivalence

between HEP and non-HEP approaches. They adopted the following conventions for interpreting

the practical or clinical implication of differences in effect size: “Equivalent”: within .1 standard

deviation of zero (greater than –.1 and less than .1); “Trivially Different”: between .1 and .2

standard deviation from zero; “Equivocal”: between .2 and .4 standard deviation from zero;

“Clinically Better/Worse”: at least .4 standard deviation from zero. These criteria for comparing

treatment effects are used across the meta-analysis.

Overall, pre-post effect sizes were large (d = .96). Weighted effect size for studies with a control

group remained large (dw = .76), a finding which remained consistent in randomised samples.

These findings indicate that approximately 80% of pre-post gains can be attributed to

experiential therapy. Effect size differences between therapies were non-significant (-.02) in

treatment comparison studies. Equivalence analyses revealed that HEP therapies were

‘equivalent’ to other approaches in general, however when compared to CBT interventions HEP

obtained ‘trivially worse’ therapy outcomes (-.13). By contrast, HEP studies showed ‘trivially

better’ (.17) effect sizes when compared to approaches other than CBT.

Researcher allegiance favoured HEPs in 65% of studies, however in studies with treatment

comparisons, the allegiance was significantly lower at just 31% pro-HEP. This finding must be

seen in the context of researchers from other theoretical orientations using relationship control

conditions which tend to be labelled as ‘supportive’ or ‘non-directive’ therapy. The contribution

of researcher allegiance has been found to represent a moderate and consistent effect on

psychotherapy outcome studies across meta-analyses (Munder, Brütsch, Leonhart, Gerger, &

Barth, 2013). Compounding this issue, allegiance often goes unreported in meta-analyses and

only a tiny fraction of RCTs (3.2%) report it (Dragioti, Dimoliatis, & Evangelou, 2015). When

equivalence analyses were repeated controlling for researcher allegiance, Elliott et al. (2013)

found that all differences between therapies were reduced to ‘equivalent’ effect sizes (dw = -.03

to .06).

Experiential therapies vary in the degree to which therapists guide the process. Traditional

person-centred therapy and supportive therapy generally have a lower degree of process-

guiding, whereas other experiential approaches such as emotion-focused therapy have a much

higher degree of process-guiding elements. The review by Elliott et al. (2013) classified HEP

approaches as either low or high on process-guiding, then compared the effect sizes to see

whether there were any measurable differences. Experiential approaches which were low on

process-guiding were found to be trivially worse than CBT (-.16), whereas those approaches

Page | 7

which were high on process-guiding were equivalent. This finding will be discussed further in the

sections which follow, related to each problem area.

Depression

Overall, the review by Elliott et al. (2013) found equivalent effect sizes between experiential

therapies and other approaches in treatment comparison trials. Therapies which were more

process-guiding (EFT and Gestalt) had a clinically significant advantage over less process-guiding

techniques (dw = .44). Elliott et al. identified three well-defined RCTs showing equivalent or

superior efficacy of EFT for depression. Applying the revised criteria of Chambless and Hollon

(1998) for empirically supported therapies (shown in Appendix 3), these results indicate that EFT

is ‘efficacious and specific’ for the treatment of depression. Likewise, four well-designed RCTs for

person-centred therapy confirm that PCT is ‘efficacious and specific’ for the treatment of

perinatal depression. This review identified three new studies focused on depression which were

not included in other meta-analyses.

A Korean study by Seo, Kang, Lee and Chae (2015) compared treatment outcomes of an 8-

session model of narrative therapy with an emotional approach (NTEA) versus treatment as

usual for a sample of chronically depressed individuals at a community mental health centre.

Significant improvements were found on measures of hope, positive affect, and depressed mood

in the NTEA group (p<.01). No change in self-awareness was detected, leading the researchers to

conclude patients may need more time in therapy to make personally meaningful change.

Cornish and Wade (2015) studied treatment outcomes for 26 individuals who were experiencing

excessive guilt over past wrongdoings, randomised either to individual EFT or waitlist. The

researchers developed a brief manualised intervention which incorporates the four R’s of

genuine self-forgiveness in EFT (i.e., responsibility, remorse, repair, and renewal). Those in the

treatment condition reported statistically significant improvement, with reduced self-

condemnation and psychological distress, in addition to increased self-forgiveness and self-

compassion (Hedge’s g>0.7).

Ellison, Greenberg, Goldman and Angus (2009) provide the first study exploring maintained gains

for emotion focused experiential therapy. Participants with moderate to severe depression were

randomised to receive either client-centred therapy or EFT for 16 to 20 sessions. Those who

responded positively to therapy (72% of those who completed treatment) were monitored

across 18 months. At the 6-month post-therapy interval there were no statistically significant

differences between groups. A difference emerged after 18 months, where survival analyses

showed that first signs of depressive relapse presented at an average of 68 weeks in the EFT

group versus 53 weeks in the client-centred therapy group.

Relationship and Interpersonal Issues

Elliott et al. (2013) highlight that the most consistently positive outcomes for experiential

therapies are associated with clients who present with relational distress. The weighted mean

effect size across 23 samples was large but variable (dw = 1.27) with larger effects found for

couple or family therapy (dw = 1.5) by comparison to individual therapy (dw = .97). Of the 11

controlled comparisons (with seven RCTs) the review identified very large treatment effects

Page | 8

(dw = 1.39). Superior treatment effects for relationship difficulties were found for experiential

therapies compared to other therapies, including CBT (dw = .34). Emotion focused therapy (for

individuals or couples) produced significantly larger effect sizes (dw = .69) than person-centred

therapy (dw=-.08). Applying the criteria of empirically supported therapies (Chambless & Hollon,

1998), the data shows that EFT for both individuals and couples is ‘efficacious and specific’ in the

care of people presenting with unresolved relationship issues. It is noteworthy that this

population includes those who have survived abuse or have found themselves in relationships

fractured by infidelity and/or trauma.

This review identified four additional studies relevant to relationship problems which were not

included in the recent meta-analysis by Elliott et al. (2013).

A study by MacIntosh and Johnson (2008) tracked therapeutic outcomes for a small group of

couples (N = 10) seeking EFT where one partner reported child sexual abuse and met the criteria

for PTSD. The couples completed an average of 19 sessions. Half of those with a traumatic

background of child sexual abuse reported clinically significant improvement to trauma

symptoms at post-treatment. All survivors of child abuse showed clinically significant

improvement on the Clinician Administered PTSD Scale, with 80% no longer meeting the criteria

for PTSD at the end of the study. Qualitative analyses of client experiences in session identified

emotional flooding, emotional numbing, dissociation, restricted range of affect, hypervigilance

to attachment figures, and issues with sexuality in the relationship. The researchers recommend

that therapists use additional structure in such work, gradually increasing the level of emotional

challenge as therapy progresses. One particularly helpful suggestion is for therapists to carefully

intervene during moments where trauma-based shame is being expressed. The intention here is

to help survivors notice the love and care their partners feel for them in the present.

Dalgleish et al. (2015) conducted a pre-post intervention study investigating the potential

predictor variables of positive outcomes with EFT for couples. A total of 31 couples showing

attachment insecurity were assessed for attachment anxiety, attachment avoidance, emotional

control, and relationship trust. Hierarchical linear modelling showed that those experiencing

higher levels of emotional control and attachment anxiety reported greater changes in marital

satisfaction after receiving therapy. Baseline measures of attachment avoidance and relationship

trust were not significant predictors of outcome. The authors conclude that EFT for couples

represents an opportunity for emotional connection for those with fears about disconnection,

recommending that practitioners could identify such people prior to commencing therapy.

Overall, the intervention showed a strong effect size (Cohen’s d = .81) on the Dyadic Adjustment

Scale with 64% of couples meeting criteria for reliable change at post-test.

A study by McRae, Dalgleish, Johnson, Burgess-Moser and Killian (2014) looked specifically at

predictor variables for blamer softening events in EFT for couples. In emotionally-focused couple

therapy, the blamer softening event is a key indicator of treatment success. Blamer softening

events occur when “a previously hostile/critical partner asks, from a position of vulnerability and

within a high level of emotional experiencing, for reassurance, comfort, or for an attachment

need to be met” (Bradley & Furrow, 2004, p. 234). Hence, blamer softening is theoretically

regarded to correspond with repair of the relationship. A sample of 32 heterosexual couples

Page | 9

with no diagnosed mental health conditions participated in an average of 21 sessions of EFT.

Blamer softening events were not predicted by any of the identified intake variables, such as

level of emotional control or emotional self-awareness. However, the researchers did observe

that levels of emotional experiencing increased over the course of therapy. Although men

reported significantly lower levels of emotional experiencing in best-rated sessions, gender was

not predictive of blamer-softening events.

Another important process study by McKinnon and Greenberg (2013) examined the role of trust

within the relationship and the expression of vulnerability in therapy. In this study, 25 couples

received up to 12 sessions of EFT, where at least one person in the relationship reported feeling

angry or hurt associated with a recent emotional injury. Couples rated sessions significantly

more positively (p=.008) when vulnerable emotions were expressed, with no significant

differences in partner perspective for that rating. Those couples who had at least one session

where vulnerable emotions were expressed showed significantly greater trust at post-test

(p=.016), but no significant differences on measures of dyadic adjustment or unfinished

business.

Anxiety

The meta-analysis by Elliott et al. (2013) identified a significant pre-post effect size for the

treatment of anxiety with experiential therapies overall (dw = .94), however the confidence

interval for this calculation revealed significant variability in outcomes. Supportive therapy had

considerably smaller treatment effects (dw = .66) than other experiential approaches.

Experiential therapy was least effective for the treatment of anxiety, with a consistent and

moderately significant effect favouring CBT (dw =-.39). Further analyses of the subtype of anxiety

disorder show that the evidence clearly favours CBT for generalised anxiety disorder (dw=-.44),

somewhat favours CBT for panic and agoraphobia (dw=-.39), and is equivocal for phobia and

social anxiety (dw=-.15). There is a noticeable gap in the research on the effectiveness of

experiential therapy for PTSD. After researcher allegiance effects were controlled, the overall

difference in effect size was reduced to -.21 which is in the ‘equivocal’ range. Given these results,

experiential therapies meet classification as possibly efficacious for the treatment of anxiety

(Chambless & Hollon, 1998). Elliott et al. suggest that anxiety disorders may respond better to

more structured therapy approaches.

In broader terms, the meta-analysis by Elliott et al. (2013) found that experiential approaches

with more process-guiding elements were equivalent to less process-guiding therapies in RCTs

(.08). However, the RCTs included in that meta-analysis show that experiential therapies with

more process-guiding elements are trivially better than CBT (.12). In a separate meta-analytic

study focused on anxiety, Elliott (2013) makes the point that experiential avoidance and a

dysregulated sense of self are commonly reported by those with anxiety. He argues that a lack of

structure in the early stages of therapy can be an unbearable experience for those struggling

with anxiety. A more active and process-guiding stance may enhance experiential therapy when

working with anxious client populations.

In his review of anxiety research, Elliott (2013) concludes that experiential therapies show

reasonable pre-post effects (.88), with weaker effect sizes in controlled studies (.5), and negative

Page | 10

effect sizes in comparison trials (-.39). It is worth noting that all but one of the comparisons were

with some form of CBT, however, even when researcher allegiance effects were controlled

statistically, the negative result for comparative effect size was still statistically significant (-.21).

Elliott draws attention to the small number of studies investigating the use of experiential

therapy with anxiety, but shows that more recent studies (such as the Strathclyde Social Anxiety

Project) have found superior comparative effect sizes for EFT (.62) over non-directive person-

centred approaches of up to 20 sessions.

A process study by Holowaty and Paivio (2012) relevant to anxiety disorders was identified in

this review of recent studies. In this study, nine therapists provided individualised EFT for 29

people with memories of child abuse. Half of the sample met diagnostic criteria for PTSD with a

mean level of symptom severity in the moderate range. Client-rated helpful events in therapy

were associated with significantly greater levels of emotional arousal and were significantly

more focused on memories of child abuse. The emotions identified by clients were primarily

anger, followed by sadness and fear. Although depth of experiencing was found to be relatively

consistent across therapy events, those who showed the deepest level of experiencing identified

helpful events which evoked significantly greater depth for them. The researchers suggest that

this finding may reflect that individuals differ in terms of their capacity to engage with emotional

depth over time. This study also highlights the positive function of providing space for clients to

express anger safely in therapy when working on childhood trauma.

Coping with Chronic Medical Conditions

Support groups using an experiential approach have commonly been applied to help people with

serious medical illnesses. The meta-analysis by Elliott et al. (2013) found a moderate but highly

inconsistent pre-post effect size (dw = .57) for experiential support groups overall. Weighted

effect sizes varied by type of health condition, ranging from .68 for autoimmune conditions, .55

for early stage cancer, .62 for early/late cancer combined, to as low as .42 for other medical

problems. Direct comparisons of experiential therapy to non-experiential therapy show a

consistent finding of equivalence, with a weighted effect size of exactly zero. This general finding

of equivalence to other established treatments for the same medical conditions led Elliott et al.

to cautiously suggest that experiential therapies meet the criteria to be identified as efficacious

for psychological coping (Chambless & Hollon, 1998), setting aside the problem of clustering

various medical conditions together in the same category. It should be noted that a Cochrane

review has concluded that there is insufficient evidence to support psychological group therapies

of any kind as a routine treatment for women diagnosed with metastatic breast cancer

(Edwards, Hulbert-Williams, & Neal, 2008). Given the moderate and positive post-therapy effect

on psychological outcomes, obvious questions are raised about how to identify those cases

where treatment is indicated.

This review identified two additional studies which could shed some light on how that question

might be addressed. McLean, Walton, Rodin, Esplen and Jones (2013) carried out a randomised

trial comparing EFT for couples with treatment as usual for 42 patients with end-stage terminal

cancer. Up to eight sessions of support were provided to patients and their carers (as couples)

over a 3-month period. A large post-treatment effect size was found for EFT (Cohen’s d = 1.00)

Page | 11

on measures of marital functioning (p < .0001), which was maintained at 3-month follow-up.

Improvement to marital distress was in the clinically significant range for 91% of patients in the

EFT group, compared to 28% in the control group (χ2 = 16.8, p<0.0001). In addition, patients who

received EFT reported a statistically significant improvement to their perceptions of carer

empathy. Although there was no significant improvement in depression over that brief period of

therapy, the reported gains to relationship functioning and perception of empathy are clearly

important to consider in the management of terminal cancer.

Another study by Herschbach et al. (2009) explored the role of group therapy in treating fears of

illness progression among an in-patient sample of 348 patients with a diagnosis of either chronic

arthritis or cancer. Patients were randomised to receive either supportive expressive group

therapy, CBT group therapy, or treatment as usual across four sessions. Outcomes were assessed

at post-test and follow up at three months and 12 months. Cancer patients showed

improvement to dysfunctional fears of illness progression, with equivalent treatment effect sizes

for both CBT (.54) and supportive-expressive (.5) group therapy. It is worth noting that measures

of depression, health-related quality of life, and life satisfaction decreased across time for cancer

patients staying in hospital, however, it was only those receiving group therapy who continued

to improve after discharge. Neither of the active treatments were successful in significantly

improving outcomes for those diagnosed with chronic arthritis. Given that people with chronic

arthritis reported higher baseline fears of illness progression and lower physical quality of life

(both at p<0.001), the researchers conclude that specific illness characteristics must be factored

into consideration when selecting appropriate forms of psychological care for individual

patients.

Children and Young People

A review by Hölldampf et al. (2010) provides a recent update of outcome studies about person-

centred and experiential psychotherapies with children and young people. The review identified

83 unique studies of which 34 were RCTs. Broadly speaking, the provision of experiential therapy

led to positive outcomes in the treatment of mood disorders, anxiety, adjustment disorder,

PTSD, mental retardation and developmental disorders, and ADHD. The largest treatment effects

were found in the treatment of children experiencing symptoms of distress related to

adjustment reactions to stressful life events, trauma, and anxiety disorders. In addition to

symptom measures, the authors note that most studies included other relevant variables to the

target problem, including social skills, emotional adjustment and assessment of the parental

relationship. The chapter concluded with a brief mention of a meta-analysis of outcome studies

aiming for publication in the coming years.

McArthur et al. (2013) explored the therapeutic outcomes of school-based humanistic

counselling in the UK. Young people aged 13 to 16 were randomly assigned to either therapy or

waitlist with pre and post-test of psychological distress and adjustment after 12 weeks. Those

who were assigned to humanistic counselling showed significantly greater reduction of distress

than controls on the CORE (Hedges g=1.14) with strong treatment effects also found on

measures of adjustment (g=.73).

Page | 12

In Australia, Havighurst, Wilson, Harley and Prior (2009) evaluated a parenting program

informed by the emotion-focused approach called ‘Tuning in to kids’. A sample of 218 parents of

children aged four to five years were randomised to either waitlist or treatment in a 6-week

group program on parenting. Parent self-evaluations before and after treatment showed large

(2) treatment effect sizes for increased emotion coaching and decreased emotion dismissing.

Child problem behaviour was significantly improved, with only 13% of parents who participated

in the group indicating problems in the clinically significant range at post-test. By comparison,

parents in the waitlist indicated that clinically significant child problem behaviour was relatively

unchanged (26% at pre-test and 28% at post-test).

A more recent trial by Havighurst, Duncombe, Frankling, Holland, Kehoe and Stargatt (2015)

evaluated a similar intervention for a larger sample of parents of children in lower school aged

between five and eight years. Child behaviour problems were identified by high scores on

combined parent and teacher ratings. In this study both parents and children were provided with

an 8-session program, with teachers of those children also being provided with six hours of

training on building more emotionally responsive teacher-student relationships. The researchers

report significant decreases in emotion dismissing and increased empathy, with moderate effect

sizes for both. Although some positive improvement occurred in the waitlist across time,

children who participated in the intervention showed significantly greater improvement in their

emotional understanding.

Psychosis

Elliott et al. (2013) offer cautious conclusions regarding the state of current evidence relating to

work with psychosis. The reviewers point out that guidelines in the UK (NICE, 2014) state: “Do

not routinely offer counselling and supportive psychotherapy (as specific interventions) to

people with schizophrenia”. The impact of such a statement in terms of public doubt has been

profoundly negative. Support groups for people living with schizophrenia across the last few

decades in the UK are now no longer offered. Elliott et al. reanalysed the same data from the

nine studies referred to in the NICE guidelines, revealing a trivially small advantage of CBT with

psychosis (d = -.19) with significant variability in outcomes. Elliott points out that many of the

therapy approaches described as ‘person-centred’ by the NICE guideline were in fact a mixture

of supportive interventions, only some of which were bona fide experiential approaches.

The wider meta-analysis by Elliott et al. (2013) includes six outcome studies on the treatment of

psychosis with a large weighted effect size overall (dw = 1.08). There were no studies comparing

humanistic experiential therapies to waitlist controls. Five comparative treatment trials in the

review showed a consistent and moderately positive effect size (dw = .39). Using the Chambless

and Hollon (1998) criteria, this finding classifies experiential therapy as ‘possibly efficacious’.

Other Conditions

Studies about various other problem areas were also included in the review by Elliott et al.

(2013), including substance abuse and eating disorders. Experiential approaches for substance

misuse have been found to be superior to non-treatment controls and either equivalent or

superior to an already established treatment (i.e., CBT) in at least two independent trials.

Page | 13

This meets criteria as an ‘efficacious’ treatment approach, with a strong effect size for working

with substance misuse (dw=.68). As the review only identified two small studies about

overeating, with a finding of no difference between treatments, the results remain equivocal for

eating disorders.

Qualitative Outcomes

Timulak and Creaner (2010) carried out a qualitative meta-analytic synthesis which drew

together descriptive report of clients about positive and negative outcomes of humanistic

therapies. Data were drawn from nine studies involving 108 clients using a variety of qualitative

methods; in most cases emotion-focused therapy or person-centred therapy. Positive outcomes

were nested in three main meta-categories (1) appreciating experiences of self, (2) appreciating

experiences of self in relation to others, and (3) a changed view of self/others. Negative

outcomes included a sense that problems were not fully resolved, being overwhelmed, feeling

harmed by the therapist, fears of changing, and disappointment at not being understood. The

reviewers note the overlap of their findings with prior meta-analyses on the same topic (Elliott,

2002), identifying that their analysis revealed several qualitatively distinct additional categories:

appreciating vulnerability, enjoying change, and feeling supported. It is interesting to note that

these subjective outcomes align with the goals and underlying philosophy of experiential

approaches.

Facilitative Conditions

The core therapist-offered conditions proposed by Rogers (1957) as necessary and sufficient for

change have been explored by researchers both individually and in the context of efficacy

research for person-centred therapy (PCT). Early meta-analyses identify medium effect sizes for

PCT (Smith, Glass, & Miller, 1980) with larger effects in practice settings (d = 1.32), equivalent to

CBT (d = 1.27) and psychodynamic therapy (d = 1.23) (Stiles, Barkham, Twigg, Mellor-Clark, &

Cooper, 2006). The review by Elliott et al. (2013) found PCT to be only equivocally less effective

than CBT, however it was noted that PCT was often used as a minimum-training relationship

control condition, meaning that in most cases what was described as PCT was not actually

intended to be therapeutic.

Taken separately, a significant proportion of outcome variance can be apportioned to each of

the facilitative conditions. Wampold and Imel (2015) report that up to 9% of outcome variance

can be apportioned to therapist empathy. However, Elliott, Bohart, Watson and Greenberg

(2011) point out that empathy is a complex construct. Empathy appears to be less predictive of

outcomes with more experienced therapists. Moreover, not all clients respond well to open

expressions of empathy. Empathy also seems to be more closely linked to outcome in CBT

(r=.31) but less associated with outcome in psychodynamic therapy (r=.19) compared to

experiential therapy (r=.26). A review by Farber and Doolin (2011) shows that positive regard is

more closely associated with positive outcomes in psychodynamic therapy (r=.52) than other

approaches (r=.12 to .33). Kolden, Klein, Wang and Austin (2011) review the status of research

about the contribution of congruence, reporting that outcomes are mixed but mainly positive.

Effect sizes range from negative (r = -.26) to strongly positive (r = .69), with the overall weighted

mean effect size for congruence showing a moderately positive effect (r = .24).

Page | 14

Client ratings of therapist empathy predict improvement in client attachment style post-therapy:

leading to reports of less insecurity, more self-acceptance, and greater levels of self-protection

(Watson, Steckley, & McMullen, 2014). Recent studies highlight the mediating role of affect

regulation on in-session emotional processing, working alliance, and outcome (Watson,

McMullen, Prosser, & Bedard, 2011). This evidence is consistent with the view that empathy

offered by a therapist cultivates self-empathy in a client, which may in turn assist people to

make positive life changes (Barrett-Lennard, 2015). In summary, whether investigation has

targeted the facilitative conditions as separate elements or as a unified treatment approach in

the form of PCT, these core conditions for therapy remain central to psychotherapy practice.

Therapeutic Alliance

Elliott et al. (2013) report that the accumulated evidence indicates that there is a moderately

strong relationship between the therapeutic alliance and outcome, setting aside some of the

complex factors involved and methodological problems in the research to date. Watson and

Geller (2006) have noted the conceptual overlap of facilitative conditions with the therapeutic

alliance, drawing attention to the strong and positive correlation of ratings on the Barrett-

Lennard Relationship Inventory (BLRI) and alliance measures (.72). The review by Elliott et al.

(2013) draws together a range of studies which suggest that relationship variables in therapy

may play an important role in subsequent changes to client affect regulation, attachment style,

and other positive therapy outcomes. Despite the attention that the alliance has received in

research in recent decades, significant questions remain about the definition of the construct

and the direction of the relationship between alliance and outcome (Doran, 2016). Nevertheless,

the therapeutic alliance remains the most robust predictor of outcome across the common

factors (Tracey, Lichtenberg, Goodyear, Claiborn, & Wampold, 2003).

Depth of Experiencing

Watson, Greenberg and Lietaer (2010) review the research relevant to both the therapeutic

alliance and the client’s experiential self-reflection (aka ‘depth of experiencing’). These two

psychotherapy process factors are central to the theory of psychological change proposed by

Carl Rogers (1957). Although Watson et al. (2010) note that interpretation of the current state of

research is limited by common methodological flaws, the authors do reveal some valuable

findings. With widely used measures such as the Experiencing Scale, researchers have explored

the degree to which people are engaged in their experiences, from detached narration through

to a more focused, open, and free-flowing synthesis of feelings and meanings. Watson et al.

(2010) report a consistent relationship between depth of experiencing and positive outcomes,

but that depth of experiencing does not appear to increase over time, as initially proposed by

Rogers (1961). Conversely, some research does suggest that depth of experiencing may increase

from early to late stages of therapy when ratings are obtained from segments of therapy linked

more directly to the core problems identified by the client (e.g., Goldman, Greenberg, & Pos,

2005).

Watson et al. (2010) review studies showing that exploration of emotions in session has been

found to be beneficial across a range of psychotherapy approaches (e.g., PCT, CBT,

psychodynamic). People who achieve more favourable results from psychotherapy begin,

Page | 15

continue, and end with greater depth of exploration, refer to their emotions more often, are

more inwardly focused, and draw from their experiences to find new meaning and purpose.

A frequency of 25% of time spent in therapy focused on moderate to high levels of emotional

arousal has been associated with optimal therapy outcomes. Consistent with emotion-focused

theories of change, the expression of greater levels of emotion at mid-treatment has been linked

with better outcomes (Pos, Greenberg, & Warwar, 2009), however there is some indication that

the strength of this effect may be constrained by earlier processes in therapy.

Structured approaches

Vos et al. (2014) conducted a meta-analysis with entry criteria strictly limited to studies which

explicitly stated that the approach being investigated was existential in focus. A total of 21 RCTs

were identified from 15 samples with 1,792 participants, with most studies describing meaning-

based therapies or supportive-expressive approaches for clients with cancer or other chronic

physical illness. For these structured approaches, large post-treatment effect-sizes were

identified post-intervention (d = 0.65) and follow-up (d = 0.57), with moderate effects on

psychopathology (d = 0.47) and self-efficacy (d = 0.48). No significant effects were found on

measures of self-reported physical health. By comparison, supportive-expressive therapy had

small effects at posttreatment and follow-up on psychopathology (d = 0.20 and 0.18,

respectively). No significant effects on self-efficacy and self-reported physical well-being were

identified. Vos et al. (2014) note the similarity of outcomes for structured existential approaches

by comparison to other psychological interventions widely used for this client group (e.g.,

mindfulness and acceptance-based therapies and support groups).

Discussion

This review has found clear and consistent evidence for the effectiveness of experiential

approaches for depression and unresolved relational issues. It is noteworthy that this

therapeutic modality meets the highest standard of evidence (i.e., ‘specific and efficacious’). Yet

there is no indication that experiential therapies will be added to the list of approved therapies

for use in government-funded programs in Australia, for example the Better Access initiative.

Research on the application of EFT to cases of relationship dysfunction involving PTSD and

attachment insecurity requires more replication to confirm the early promising findings

identified in this review.

The evidence supporting experiential therapy for anxiety disorders is inconsistent and

comparatively weaker. The ‘possibly efficacious’ status of experiential therapy warrants further

attention by researchers to clarify whether bringing further structure into these approaches

could improve outcomes. Given that all but one of the RCT comparisons were made to CBT with

‘supportive therapy’ being generally intended as a control group, it is unclear whether bona fide

therapies were being applied. The present state of uncertainty about therapies used as control

conditions makes it difficult to interpret findings on a wider scale. Researchers should ensure

that training and allegiance of therapists in both types of therapy being compared should be

reasonably consistent in future RCTs. Alternatively, researchers should consider more clearly

labelling specific types of therapy (rather than simply calling them ‘supportive’) so that reviewers

Page | 16

do not erroneously include relationship control groups which were not intended to be

therapeutic.

This review highlights the need for more comparison trials to be carried out on the use of

experiential therapy to manage psychosis. While the current data indicates that this class of

therapy is ‘possibly efficacious’, there are similar problems in the psychosis research to those

described for anxiety disorders. At present, the NICE guidelines in the UK specify that people

with psychosis should be routinely offered CBT rather than supportive therapy (NICE, 2014),

however there is little, if any data, to suggest the superiority of CBT. For example, a Cochrane

review found that CBT is no better or worse than other talking therapies for schizophrenia

(Jones, Hacker, Cormac, Meaden, & Irving, 2012). Other recent reviews show modest effects of

CBT for psychosis, which has raised concerns that public treatment guidelines over-promote CBT

and understate other viable alternatives (Jauhar, McKenna, Radua, Fung, Salvador, & Laws,

2014).

The research on experiential therapies for medical conditions is of considerable importance.

Rates of co-morbid mental health disorders remain high for those diagnosed with cancer, with

estimates ranging from 20% to 50% of such patients also meeting diagnostic criteria for

depression or anxiety (Pasquini & Biondi, 2007). Conversely, longitudinal research spanning 18

years has now identified depression as an independent risk factor for coronary heart disease in

women, with a greater magnitude of association between these conditions than other typical

and atypical risk factors (O’Neill et al., 2016). The close association of high prevalence mental

disorders and serious physical illness highlights the need for flexible and personally relevant

psychotherapy approaches. Rather than attempting to directly target physical symptoms, the

aim of such therapies is to improve quality of life, increase levels of interpersonal support, and

optimise meaningful recovery wherever possible.

This review identifies that experiential therapies are equivalent to other well-established

therapies aimed at improving psychological coping. There is also evidence that structured

meaning-based existential therapies can effectively reduce psychopathology and increase self-

esteem for people with cancer and other chronic health problems. The benefits of therapy were

not merely temporary but sustained at follow-up. On this basis, it is suggested that experiential

approaches should be made accessible to people with co-occurring mental disorders and serious

health conditions such as cancer.

This review highlighted a collection of studies that confirm the ongoing relevance of the

therapist-offered facilitative conditions proposed by Rogers (1957), most notably therapist

empathy. Emerging process research on therapist empathy suggests a role in helping clients

develop self-compassion and self-care, which again is consistent with humanistic theories of

change. It is unclear from the current state of research whether depth of experiencing increases

as therapy progresses, however the expression of deeper levels of emotion in therapy in the

early and middle stages of therapy has been associated with better outcomes. Further research

is needed to establish a clearer link between process factors in experiential therapy and later

outcomes.

Page | 17

Limitations

Reviewers across this body of literature highlight methodological challenges which limit the

conclusions which can be drawn from the existing research. Elliott et al. (2013) draw attention to

variation in the level of rigour across qualitative studies, and the need for more consistently high

standards. Process and outcome studies of experiential therapy face challenges around the use

of inconsistent measures, relying on small samples without follow-up, and variability in the level

of therapist experience (Krycka & Ikemi, 2016; Watson et al., 2010). The review noted significant

differences between studies for which a segment of therapy was sampled, in which detection of

the key therapeutic process is paramount. Murphy and Joseph (2016) raise concerns that the

common single group pre-test post-test design of studies of humanistic therapies does not allow

us to draw conclusions about comparative efficacy. In addition, it is noteworthy that

comparisons of high versus low process-guiding in most cases are carried out by researchers who

have an allegiance with high process-guiding therapies (generally EFT). Allegiance effects remain

an ongoing issue in psychotherapy research, and as this review has shown, they can have subtle

but far ranging consequences.

Conclusions

There is a need for experiential therapists to co-develop and take part in large-scale research

projects. The limitations and gaps in the research identified in this review can be addressed, but

will require support from universities and organisations dedicated to promoting psychotherapy

such as PACFA. A major obstacle for Australia is the recent closure of multiple postgraduate

training programs where experiential approaches were a key component of the course (Di

Mattia & Grant, 2016). It is unlikely that research of the required type will be carried out in

Australia if there are no postgraduate training institutions bringing new therapists and

researchers into these approaches to therapy.

Despite these challenges, counselling and psychotherapy practitioners remain dedicated and

engaged with experiential therapy, a modality which clearly deserves greater recognition and

support in Australian public policy. The findings of this review make it clear that this therapy

modality should be approved for use with depressive disorders and in cases of significant

relationship dysfunction. It is recommended that structured experiential approaches should

also be made accessible to people with co-morbid medical issues, to align with client treatment

preferences. Experiential work with anxiety disorders should be managed more carefully,

supporting clients who prefer these approaches with a greater level of structure and increased

therapist guidance around therapeutic processes.

Page | 18

References

Angus, L., Watson, J. C., Elliott, R., Schneider, K., & Timulak, L. (2015). Humanistic psychotherapy

research 1990–2015: From methodological innovation to evidence-supported treatment

outcomes and beyond. Psychotherapy Research, 25(3), 330-347.

Barrett-Lennard, G. T. (2015). The relationship inventory: A complete resource and guide.

Chichester, England: John Wiley & Sons.

Bradley, B., & Furrow, J. L. (2004). Toward a mini-theory of the blamer softening the moment by

moment process. Journal of Marital and Family Therapy, 30, 233–246.

Cain, D. J., Keenan, K., & Rubin, S. (2016). Humanistic psychotherapies: Handbook of research

and practice (2nd ed.). Washington, DC: American Psychological Association.

Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported therapies. Journal of

Consulting and Clinical Psychology, 66(1), 7-18.

Cornish, M. A., & Wade, N. G. (2015). Working through past wrongdoing: Examination of a self-

forgiveness counseling intervention. Journal of Counseling Psychology, 62(3), 521-528.

Dalgleish, T. L., Johnson, S. M., Moser, M. B., Lafontaine, M., Wiebe, S. A., & Tasca, G. A. (2015).

Predicting change in marital satisfaction throughout emotionally focused couple therapy.

Journal of Marital and Family Therapy, 41(3), 276-291.

Di Mattia, M., & Grant, J. (2016). Counselling psychology in Australia: History, status and

challenges. Counselling Psychology Quarterly, 29(2), 139-149.

Doran, J. M. (2016). The working alliance: Where have we been, where are we

going? Psychotherapy Research, 26(2), 146-163.

Dragioti, E., Dimoliatis, I., & Evangelou, E. (2015). Disclosure of researcher allegiance in meta-

analyses and randomised controlled trials of psychotherapy: A systematic appraisal. British

Medical Journal Open, 5(6), 1-10.

Elliott, R. (2002). Render unto Caesar: Quantitative and qualitative knowing in research on

humanistic therapies. Person-centred and Experiential Psychotherapies, 1, 102-117.

Elliott, R. (2013). Person-centred/experiential psychotherapy for anxiety difficulties: Theory,

research and practice. Person-centred and Experiential Psychotherapies, 12(1), 16-32.

Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. In J. C. Norcross (Ed.),

Psychotherapy relationships that work (2nd ed., pp. 132-152). New York, NY: Oxford

University Press.

Ellison, J. A., Greenberg, L. S., Goldman, R. N., & Angus, L. (2009). Maintenance of gains following

experiential therapies for depression. Journal of Consulting and Clinical Psychology, 77(1),

103-112.

Page | 19

Elliott, R. Greenberg, L. S., Watson, J., Timulak, L., & Freire, E. (2013). Research on humanistic-

experiential psychotherapies. In M. J. Lambert (Ed.), Bergin & Garfield’s Handbook of

psychotherapy and behavior change (6th ed., pp. 495-538). New York, NY: Wiley.

Edwards, A. G., Hulbert-Williams, N., & Neal, R. D. (2008). Psychological interventions for women

with metastatic breast cancer. Cochrane Database Systematic Reviews, (3). doi:

10.1002/14651858.CD004253.pub3.

Farber, B. A., & Doolin, E. M. (2011). Positive regard and affirmation. In J. C. Norcross (Ed.),

Psychotherapy relationships that work (2nd ed., pp. 168-186). New York, NY: Oxford

University Press.

Goldman, R. N., Greenberg, L. S., & Pos, A. E. (2005). Depth of emotional experience and

outcome. Psychotherapy Research, 15, 248-260.

Havighurst, S. S., Wilson, K. R., Harley, A. E., & Prior, M. R. (2009). Tuning into kids: An emotion-

focused parenting program - Initial findings from a community trial. Journal of Community

Psychology, 37(8), 1008-1023.

Havighurst, S. S., Duncombe, M., Frankling, E., Holland, K., Kehoe, C., & Stargatt, R. (2015). An

emotion-focused early intervention for children with emerging conduct problems. Journal

of Abnormal Child Psychology, 43(4), 749-760.

Herschbach, P., Berg, P., Waadt, S., Duran, G., Engst-Hastreiter, U., Henrich, G., Book, K., &

Dinkel, A. (2009). Group psychotherapy of dysfunctional fear of progression in patients

with chronic arthritis or cancer. Psychotherapy and Psychosomatics, 79(1), 31-38.

Hölldampf, D., Behr, M., & Crawford, I. (2010). Effectiveness of person-centred and experiential

psychotherapies with children and young people: A review of outcome studies. In M.

Cooper, J. C. Watson, & D. Hölldampf (Eds.), Person-centred and experiential therapies

work (pp. 16-44). Ross-on-Wye, England: PCCS Books.

Holowaty, K. A. M., & Paivio, S. C. (2012). Characteristics of client-identified helpful events in

emotion-focused therapy for child abuse trauma. Psychotherapy Research, 22(1), 56-66.

Jauhar, S., McKenna, P. J., Radua, J., Fung, E., Salvador, R., Laws, K. R. (2014). Cognitive-

behavioural therapy for the symptoms of schizophrenia: Systematic review and meta-

analysis with examination of potential bias. The British Journal of Psychiatry, 204(1), 20-29

Jones, C., Hacker, D., Cormac, I., Meaden, A., & Irving, C. B. (2012). Cognitive behavioural therapy

versus other psychosocial treatments for schizophrenia. Retrieved from

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008712.pub2

Kolden, G. G., Klein, M. H., Wang, C., & Austin, S. B. (2011). Congruence/genuineness. In J. C.

Norcross (Ed.), Psychotherapy relationships that work (2nd ed.) (pp. 187-202). New York,

NY: Oxford University Press.

Page | 20

Krycka, K. C., & Ikemi, A. (2016). Focusing-oriented experiential psychotherapy: From research to

practice. In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook

of research and practice (2nd ed., pp. 251-282). Washington, DC: American Psychological

Association.

MacIntosh, H. B., & Johnson, S. (2008). Emotionally focused therapy for couples and childhood

sexual abuse survivors. Journal of Marital and Family Therapy, 34(3), 298-315.

McLean, L. M., Walton, T., Rodin, G., Esplen, M. J., & Jones, J. M. (2013). A couple-based

intervention for patients and caregivers facing end-stage cancer: Outcomes of a

randomized controlled trial. Psycho-Oncology, 22(1), 28-38.

McKinnon, J. M., & Greenberg, L. S. (2013). Revealing underlying vulnerable emotion in couple

therapy: Impact on session and final outcome. Journal of Family Therapy, 35(3), 303-319.

McRae, T. R., Dalgleish, T. L., Johnson, S. M., Burgess-Moser, M., & Killian, K. D. (2014). Emotion

regulation and key change events in emotionally focused couple therapy. Journal of Couple

and Relationship Therapy, 13(1), 1-24.

Munder, T., Brütsch, O., Leonhart, R., Gerger, H., & Barth, J. (2013). Researcher allegiance in

psychotherapy outcome research: An overview of reviews. Clinical Psychology Review,

33(4). 501-511.

Murphy, D., & Joseph, S. (2016). Person-centred therapy: Past, present, and future orientations.

In D. J. Cain, K. Keenan, & S. Rubin (Eds.), Humanistic psychotherapies: Handbook of

research and practice (2nd ed., pp. 185-218). Washington, DC: American Psychological

Association.

National Institute for Health and Care Excellence (NICE). (2014). Psychosis and schizophrenia in

adults: Prevention and management. NICE clinical guideline (CG178). Retrieved from

https://www.nice.org.uk/guidance/cg178

O’Neill, A., Fisher, A. J., Kibbey, K. J., Jacka, F. N., Kotowicz, M. A., Williams, L. J., Stuart, A. L.,

Berk, M., Lewandowski, P. A., Taylor, C. B., & Pasco, J. A. (2016). Depression is a risk factor

for incident coronary heart disease in women: An 18-year longitudinal study. Journal of

Affective Disorders, 196, 117-124.

Pasquini, M., & Biondi, M. (2007). Depression in cancer patients: A critical review. Clinical

Practice and Epidemiology in Mental Health, 3, 2. doi: http://doi.org/10.1186/1745-0179-

3-2

Pos, A. E., Greenberg, L. S., & Warwar, S. (2009). Testing a model of change for experiential

treatment of depression. Journal of Consulting and Clinical Psychology, 77(6), 1055–1066.

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change.

Journal of Consulting Psychology, 21, 95–103.

Rogers, C. (1961). On becoming a person. Boston, MA: Houghton Mifflin.

Page | 21

Seo, M., Kang, H. S., Lee, Y. J., & Chae, S. M. (2015). Narrative therapy with an emotional

approach for people with depression: Improved symptom and cognitive-emotional

outcomes. Journal of Psychiatric and Mental Health Nursing, 22(6), 379-389.

Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore, DC:

John Hopkins University Press.

Stiles, W. B., Barkham, M., Twigg, E., Mellor-Clark, J., & Cooper, M. (2006). Effectiveness of

cognitive-behavioural, person-centred and psychodynamic therapies as practiced in UK

National Health Service settings. Psychological Medicine, 36, 555-566.

Timulak, L., & Creaner, M. (2010). Qualitative meta-analysis of outcomes of person-centred and

experiential psychotherapies. In M. Cooper, J. C. Watson, & D. Hölldampf (Eds.), Person-

centred and experiential therapies work (pp. 65-90). Ross-on-Wye, England: PCCS Books.

Tracey, T. J. G., Lichtenberg, J. W., Goodyear, R. K., Claiborn, C. D., & Wampold, B. E. (2003).

Concept mapping of therapeutic common factors. Psychotherapy Research, 13(4), 401-

413.

Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on

psychological outcomes. Journal of Consulting and Clinical Psychology, 83(1), 115-128.

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate (2nd ed.). New York, NY:

Routledge.

Watson, J. C., Steckley, P. L., & McMullen, E. J. (2014). The role of empathy in promoting

change. Psychotherapy Research, 24(3), 286-298.

Watson, J. C., McMullen, E. J., Prosser, M. C., & Bedard, D. L. (2011). An examination of the

relationships among clients' affect regulation, in-session emotional processing, the

working alliance, and outcome. Psychotherapy Research, 21(1), 86-96.

Watson, J. C., Greenberg, L. S., & Lietaer, G. (2010). Relating process to outcome in person-

centred and experiential psychotherapies. In M. Cooper, J. C. Watson, & D. Hölldampf

(Eds.), Person-centred and experiential therapies work (pp. 132-263). Ross-on-Wye,

England: PCCS Books.

Wilson, D. B., & Lipsey, M. W. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage.

Page | 22

Appendix 1

The list of keywords for the name of each approach was as follows:

Experiential, focusing oriented, process experiential, emotion focused (or emotionally focused),

existential, phenomenological, phenomenology, intersubjective, constructivist, logotherapy,

psychodrama, gestalt, Hakomi,

The above list was paired with the following keywords:

Approach, therapy, psychotherapy, counselling, counseling, enquiry, psychology, analysis

Page | 23

Appendix 2

Table 1: Studies meeting inclusion criteria

Study Design Intervention Targeted problem Area(s) Participant Characteristics

Outcomes

Cornish & Wade (2015)

Randomised trial comparing treatment to waitlist with 2-month follow-up.

Brief model of EFT for individuals (8 sessions)

Psychological distress (CORE) Self-condemnation, self-condemnation, and self-compassion

26 individuals with guilt over prior wrongs

Significantly reduced self-condemnation and psychological distress, in addition to increased self-forgiveness and self-compassion (Hedge’s g>.07). Gains were maintained at 2-month follow-up.

Dalgleish et al. (2015)

Pre-post design outcome study

EFT for couples (21 session mean)

Predictor variables (attachment anxiety, emotional control, and trust)

Relationship adjustment

31 couples Strong effect size (Cohen’s d = .81) on the Dyadic Adjustment Scale (DAS) with 64% showing reliable change

High emotional control and attachment anxiety associated with greater change. Baseline attachment avoidance and relationship trust not significantly predictive.

Elliott et al. (2013)

Meta-analysis Humanistic Experiential Psychotherapies (20 session mean)

Various 14,206 individuals

Large pre-post effects (d = .96) with treatment comparisons generally non-significant (-.02). CBT trivially better (-.13) however researcher allegiance reduced to equivalent effect size range (dw = -.03 to .06)

Ellison et al. (2009)

Randomised comparison of treatment with 6-month and 18-month follow-up

EFT for individuals versus client-centred therapy (16 to 20 sessions)

Depression (moderate to severe)

43 individuals No statistically significant differences between groups at 6-months. Survival analysis shows first depressive relapse occurs at average of 53 weeks in client-centred group versus 68 weeks in EFT group.

Havighurst et al. (2009)

Randomised trial comparing treatment to waitlist

Emotion-focused group intervention for parents (6 weeks)

Behaviour problems

Parental management of child’s emotions

218 parents of pre-school children with behaviour issues

Child problem behaviour significantly improved in treatment group. Parent self-evaluation improved on management of child’s emotions.

Page | 24

Study Design Intervention Targeted problem Area(s) Participant Characteristics

Outcomes

Havighurst et al. (2015)

Randomised trial comparing treatment to waitlist

Emotion-focused group intervention for parents, teachers, and children (8 sessions)

Behaviour problems

204 primary caregivers and their children, with identified behaviour issues

Significant decreases in emotion dismissing and increased empathy, with moderate effect sizes for both. Although some positive improvement occurred in the waitlist across time, children who participated in the intervention who showed significantly greater improvement to emotional understanding and the targeted behaviour problems

Herschbach et al. (2009)

Randomised comparison of treatments

Supportive-expressive group therapy versus CBT group therapy versus TAU (4 sessions only)

Dysfunctional fears of illness progression, depression, health-related quality of life, and life satisfaction

348 patients diagnosis with either chronic arthritis or cancer

Cancer patients report significant improvement to dysfunctional fears of illness progression over time. Only those patients who attended group therapy continue to improve after discharge. Neither form of group therapy improved outcomes for patients with chronic arthritis.

Hölldampf et al. (2010)

Meta-analysis Person-centred and experiential therapies (variable length)

Various Children from 83 individual studies

Reports positive outcomes for mood disorders, anxiety, adjustment disorder, PTSD, mental retardation and developmental disorders, and ADHD. Largest effects were found in the treatment distress related to stressful life events, trauma, and anxiety disorders

Holowaty & Paivio (2012)

Process study EFT for individuals Client-rated helpful events, emotional arousal, and depth of experiencing

29 individuals with memory of child abuse

Helpful events identified by clients were associated with significantly greater emotional arousal and linked to memories of child abuse.

MacIntosh & Johnson (2008)

Pre-post design outcome study with process variables

EFT for couples (19 session mean)

Symptoms of trauma and PTSD

Relationship satisfaction

Subjective report of client experiences in session

10 couples with partner history of child sexual abuse and PTSD

Half of couples show clinically significant improvement to trauma symptoms and satisfaction with relationship at treatment completion. 80% of trauma survivors no longer met PTSD criteria at completion.

Page | 25

Study Design Intervention Targeted problem Area(s) Participant Characteristics

Outcomes

McArthur et al. (2013)

Randomised trial with waitlist control group

School-based humanistic counselling versus waitlist control (up to 9 sessions)

Psychological distress (YP-CORE)

33 young people aged 13 to 16 years

Young people who received humanistic counselling showed significantly greater reduction of distress than controls on the CORE (Hedges g=1.14) with strong treatment effects also found on measures of adjustment (g=.73)

McKinnon & Greenberg (2013)

Process study EFT for couples (up to 12 sessions)

Partner trust, dyadic adjustment, and unfinished business

25 couples with a partner angry/hurt by recent injury to emotions

Couples rated sessions significantly more positively (p=.008) when vulnerable emotions were expressed. Greater levels of trust when couples have at least one session where vulnerable emotions are expressed, but no difference to unfinished business or dyadic adjustment.

McLean et al. (2013)

Randomised trial comparing to waitlist with 3-month follow-up

EFT for couples (up to 8 sessions)

Depression, marital functioning, and perception of carer empathy

42 patients with terminal cancer

Large post-treatment effect (d = 1.00) on measures of marital functioning maintained at 3-month follow-up. Improvement to marital distress was in the clinically significant range for 91% of patients in the EFT group compared to 28% in the control group. Statistically significant improvement to perceptions of carer empathy. No significant improvement to depression.

McRae et al. (2014)

Process study EFT for couples (21 session mean)

Predictor variables for blamer softening events in therapy

32 couples Blamer softening not predicted by intake variables such as emotional control or emotional self-awareness. Levels of emotional experiencing increase over course of therapy.

Seo et al. (2015) Quasi-experimental trial comparing to TAU

Narrative therapy with emotional approach versus treatment as usual (8 sessions)

Depression 50 individuals with chronic depression medicated for 10+ years

Significant improvements to hope, positive affect, and depression (p<.01). No significant change to self-awareness.

Page | 26

Study Design Intervention Targeted problem Area(s) Participant Characteristics

Outcomes

Timulak & Creaner (2010)

Meta-analytic synthesis

Humanistic therapies (variable length)

Qualitative outcomes of therapy

108 clients Three main meta-categories identified for outcomes of humanistic therapy: (1) appreciating experiences of self, (2) appreciating experiences of self in relation to others, and (3) a changed view of self/others.

Vos et al. (2014) Meta-analysis Existential therapy Various 1792 individuals Large post-treatment effect-sizes for meaning-based existential therapies (d=.65), maintained at follow-up (d=.57), with moderate effects on psychopathology (d=.47) and self-efficacy (d=.48) at post-intervention.

Page | 27

Appendix 3

The revised criteria proposed by Chambless and Hollon (1998) for designating levels of empirical

support for psychological interventions include the following.

First, in order to meet basic standards, research about psychological intervention is expected to

meet certain quality criteria:

a) reasonable sample size (n > 25 per group);

b) use of treatment manual or adherence checks;

c) a specific client population defined by reliable, valid inclusion criteria;

d) use of reliable, valid outcome measures, including measurement of targeted client

difficulties;

e) appropriate data analysis (e.g., direct comparisons, evaluation of all outcome measures).

The three levels of efficacy are defined as:

1. Possibly efficacious: One controlled study in absence of conflicting evidence.

2. Efficacious: In at least two independent research settings, the treatment is either (a)

superior to no treatment or another treatment, or (b) equivalent to an established

treatment using studies of reasonable size (n > 25 per group). With conflicting evidence,

the preponderance of the well-controlled studies supports the treatment.

3. Efficacious and specific: In at least two independent research settings, the treatment

must have been shown to be statistically significant and superior either (a) to a non–

bona fide treatment (e.g., a “placebo”) or (b) to an alternative bona fide treatment. With

conflicting evidence, the preponderance of the well-controlled studies supports the

treatment.